Chapter

Lacrimal Drainage System 2 

Anatomy  66
Physiology  66
Causes of a watering eye  67
Evaluation  67
Acquired obstruction  70
Congenital obstruction  72
Lacrimal surgery  74
Chronic canaliculitis  75
Dacryocystitis  77
 Clinical Ophthalmology
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A S Y S T E M AT I C A P P ROAC H
Anatomy
The lacrimal drainage system consists of the following
structures (Fig. 2.1):
1. The puncta are located at the posterior edge of the
lid margin, at the junction of the lash-bearing lateral
five-sixths (pars ciliaris) and the medial non-
ciliated one-sixth (pars lacrimalis). Normally they face
slightly posteriorly and can be inspected by everting
the medial aspect of the lids. Treatment of watering
caused by punctal stenosis or malposition is relatively
straightforward.
2. The canaliculi pass vertically from the lid margin for
about 2 mm (ampullae). They then turn medially and
run horizontally for about 8 mm to reach the lacrimal
sac. The superior and inferior canaliculi most fre-
quently unite to form the common canaliculus, which
opens into the lateral wall of the lacrimal sac. In some
individuals, each canaliculus opens separately. A
small flap of mucosa (valve of Rosenmüller) over-
hangs the junction of the common canaliculus and the
Canaliculus (8 mm)
Lacrimal
sac (10 mm)
Nasolacrimal
Ampulla (2 mm) duct (12 mm)
Common canaliculus Valve of Hasner
Fig. 2.1  Anatomy of the lacrimal drainage system
A B
Fig. 2.2  Physiology of the lacrimal drainage system
lacrimal sac and prevents reflux of tears into the canal-
iculi. Treatment of canalicular obstruction is often
complicated.
3. The lacrimal sac is about 10–12 mm long and lies in
the lacrimal fossa between the anterior and posterior
lacrimal crests. The lacrimal bone and the frontal
process of the maxilla separate the lacrimal sac from
the middle meatus of the nasal cavity. In a dacryo-
cystorhinostomy (DCR) an anastomosis is created
between the sac and the nasal mucosa to bypass an
obstruction in the nasolacrimal duct.
4. The nasolacrimal duct is 12–18 mm long and is the
inferior continuation of the lacrimal sac. It descends
and angles slightly laterally and posteriorly to open
into the inferior nasal meatus, lateral to and below
the inferior turbinate. The opening of the duct is par-
tially covered by a mucosal fold (valve of Hasner).
Obstruction of the duct may cause a secondary disten-
sion of the sac.
Physiology
Tears secreted by the main and accessory lacrimal glands
pass across the ocular surface. A variable amount of the
aqueous component of the tear film is lost by evaporation.
This is related to the size of the palpebral aperture, the
blink rate, ambient temperature and humidity. The
remainder of the tears drain as follows (Fig. 2.2):
a. Tears flow along the upper and lower marginal strips
(Fig. 2.2A) and enter the upper and lower canaliculi
by capillarity and also possibly by suction.
b. With each blink, the pretarsal orbicularis oculi com-
presses the ampullae, shortens and compresses the
horizontal canaliculi and moves the puncta medially.
Simultaneously, the lacrimal part of the orbicularis
oculi, which is attached to the fascia of the lacrimal
sac, contracts and compresses the sac, thereby creating
a positive pressure which forces the tears down the
nasolacrimal duct and into the nose (Fig. 2.2B and C).
c. When the eyes open the muscles relax, the canaliculi
and sac expand creating a negative pressure which,
assisted by capillarity, draws the tears from the eye
into the empty sac.
C

Lacrimal Drainage System
Causes of a watering eye
Epiphora is defined as the sign of overflow of tears, and
may be caused by the following:
1. Hypersecretion secondary to ocular inflammation or
surface disease. In these cases watering is associated
with symptoms of the underlying cause and treatment
is usually medical.
2. Defective drainage due to compromise of the lacrimal
drainage system. This tends to be exacerbated by a
cold and windy atmosphere, and is least evident in a
warm dry room. It may be caused by:
a. Malposition of the lacrimal puncta (e.g. secondary
to ectropion).
b. Obstruction along the lacrimal drainage system,
from the puncta to the nasolacrimal duct.
c. Lacrimal pump failure, which may occur secondar-
ily to lower lid laxity or weakness of the orbicularis
muscle (e.g. facial nerve palsy).
Evaluation
External examination
1. The puncta and eyelids are best examined on the slit-
lamp for evidence of the following conditions:
• Punctal stenosis.
• Ectropion causing malposition of the punctum,
often associated with secondary stenosis (Fig. 2.3A).
• Punctal obstruction by an eyelash (Fig. 2.3B) or a
fold of redundant conjunctiva (conjunctivochalasis
– Fig. 2.3C).
• A large caruncle displacing the punctum away
from the globe (Fig. 2.3D).
• A pouting punctum is typical of canaliculitis
(Fig. 2.3E).
• Centurion syndrome is characterized by anterior
malposition of the medial part of the lid, with dis-
placement of puncta out of the lacus lacrimalis due
to a prominent nasal bridge (Fig. 2.3F).
2. The lacrimal sac should be palpated. Punctal reflux of
mucopurulent material on lacrimal compression (see
Fig. 2.22B) is indicative of a mucocele with a patent
canalicular system, but with an obstruction either at
or distal to the lower end of the lacrimal sac. In acute
dacryocystitis palpation is severely painful and com-
pression should be avoided. Rarely, palpation of the
sac will reveal a stone or a tumour.
Fluorescein disappearance test
The marginal tear strip of both eyes should be examined
on the slit-lamp prior to any manipulation of the eyelids
or instillation of topical medication, as these may preju-
dice the clinical picture. Many patients with watering do
not have obvious overflow of tears onto the face but
merely show a high marginal tear strip on the affected
side (Fig. 2.4). The fluorescein disappearance test is per-
formed by instilling fluorescein 2% drops into both con-
junctival fornices. Normally, little or no dye remains after
5 minutes. Prolonged retention is indicative of inadequate
lacrimal drainage and can be graded from 1–4.
2
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67
Probing and irrigation
Probing and irrigation are performed only after ascertain-
ing punctal patency.
a. Local anaesthetic is instilled into the conjunctival sac.
b. The lower punctum is dilated (Fig. 2.5A).
c. A gently curved, blunt-tipped 26-gauge lacrimal
cannula on a 2 mL saline-filled syringe is inserted into
the lower punctum and, whilst keeping gentle stretch
laterally on the eyelid, advanced a few mm following
the contour of the canaliculus prior to irrigation
(Fig. 2.5B). Failure of the tip of the cannula to enter the
punctum indicates stenosis or obstruction and further
dilatation of the punctum may be needed before
patency beyond can be established.
d. If irrigation confirms lacrimal obstruction an attempt
can be made to pass the tip of the cannula into the
lacrimal sac, the medial wall of which lies against the
bone of the lacrimal fossa.
e. The cannula can come either to a hard stop or to a soft
stop.
1. A hard stop occurs if the cannula enters the lacrimal
sac. It comes to a stop at the medial wall of the sac,
through which can be felt the rigid lacrimal bone
(Fig. 2.6A). This excludes complete obstruction of the
canalicular system. If the saline passes into the nose,
when it will be tasted by the patient, a patent lacrimal
system is present, although it may still be stenosed;
alternatively there may be subtle lacrimal pump
failure. Failure of saline to reach the nose is indicative
of total obstruction of the nasolacrimal duct. In this
situation, the lacrimal sac will become distended
during irrigation and there will also be reflux through
the upper punctum. The regurgitated material may be
clear, mucoid, mucopurulent or frankly purulent,
depending on the contents of the lacrimal sac.
2. A soft stop is experienced if the cannula stops at or
proximal to the junction of the common canaliculus
and the lacrimal sac, i.e. at the lateral wall of the sac.
The sac is thus not entered – a spongy feeling is expe-
rienced as the cannula presses the soft tissue of the
common canaliculus and the lateral wall against the
medial wall of the sac and the lacrimal bone behind it
(Fig. 2.6B). Irrigation will therefore not cause the sac
to distend. In the case of lower canalicular obstruction,
a soft stop will be associated with reflux of saline
through the lower punctum. Reflux through the
upper punctum indicates patency of both upper and
lower canaliculi, but obstruction of the common
canaliculus.
Jones dye testing
Dye testing is only indicated in patients with suspected
partial obstruction of the drainage system. These patients
manifest epiphora, but the lacrimal system can be success-
fully irrigated. Dye testing has high false positive and
negative rates and is of no value in the context of total
obstruction.
1. The primary test (Fig. 2.7A) differentiates partial
obstruction of the lacrimal passages from primary
hypersecretion of tears. First, a drop of 2% fluorescein
 Clinical Ophthalmology
68
A S Y S T E M AT I C A P P ROAC H

A B

C D

E F

Fig. 2.3  (A) Punctal ectropion; (B) punctal obstruction by an eyelash; (C) conjunctivochalasis; (D) large caruncle; (E) pouting
punctum; (F) centurion syndrome
(Courtesy of S Tuft – fig. C)

Lacrimal Drainage System
Fig. 2.4  High marginal tear strip stained with fluorescein
A
Fig. 2.5  (A) Dilatation of the inferior punctum; (B) irrigation
(Courtesy of K Nischal)
is instilled into the conjunctival sac. After about 5
minutes, a cotton-tipped bud moistened in a local
anaesthetic is inserted under the inferior turbinate at
the nasolacrimal duct opening. The results are inter-
preted as follows:
a. Positive: fluorescein recovered from the nose indi-
cates patency of the drainage system. Watering is
due to primary hypersecretion and no further tests
are necessary.
2
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69
A B
Fig. 2.6  Possible results of probing. (A) Hard stop; (B) soft
stop
Positive Negative
Positive Negative
Fig. 2.7  Jones dye testing. (A) Primary; (B) secondary
b. Negative: no dye recovered from the nose indicates
a partial obstruction (site unknown) or failure of
the lacrimal pump mechanism. In this situation the
secondary dye test is performed immediately.
2. The secondary (irrigation) test (Fig. 2.7B) identifies
the probable site of partial obstruction, on the basis of
whether the topical fluorescein instilled for the primary
test entered the lacrimal sac. Topical anaesthetic is
instilled and any residual fluorescein washed out. The
drainage system is then irrigated with saline with a
cotton bud under the inferior turbinate.
a. Positive: fluorescein-stained saline recovered from
the nose indicates that fluorescein entered the
 Clinical Ophthalmology
70
A S Y S T E M AT I C A P P ROAC H
lacrimal sac, thus confirming functional patency of
the upper lacrimal passages. Partial obstruction of
the nasolacrimal duct is inferred.
b. Negative: unstained saline recovered from the
nose indicates that fluorescein did not enter
the lacrimal sac. This implies partial obstruction
of the upper lacrimal passages (puncta, canaliculi
or common canaliculus) or a defective lacrimal
pump.
Contrast dacryocystography
Dacryocystography (DCG) involves the injection of radio-
opaque contrast medium into the canaliculi followed by
capture of magnified images. The test is usually per-
formed on both sides simultaneously. A DCG is not nec-
essary if the site of obstruction is obvious such as in the
case of a regurgitating mucocele. It should also not be
performed in a patient with acute dacryocystitis.
1. Indications
• To confirm the site of lacrimal drainage obstruc-
tion, especially prior to surgery.
• To diagnose diverticuli, fistulae and filling defects
caused by stones or tumours.
2. Technique
a. The inferior puncta are dilated.
b. Plastic catheters are inserted into the inferior canal-
iculi on either side; alternatively the upper puncta
may be used.
c. Contrast medium, usually 1–2 mL of Lipiodol, is
simultaneously injected on both sides and postero-
anterior radiographs are taken.
d. Ten minutes later an erect oblique film is taken
to assess the effect of gravity on tear drainage.
Digital subtraction DCG provides a higher quality
image capture than conventional.
3. Interpretation
• Failure of dye to reach the nose indicates an ana-
tomical obstruction, the site of which is usually
evident (Fig. 2.8B and C).
• A normal dacryocystogram (Fig. 2.8A) in the pres-
ence of epiphora suggests either functional obstruc-
tion or lacrimal pump failure.
Nuclear lacrimal scintigraphy
Scintigraphy is a sophisticated test which assesses tear
drainage under more physiological conditions than DCG.
Although it does not provide the same detailed anatomi-
cal visualization as DCG, it is more sensitive in assessing
incomplete blocks. It is also useful in assessing physiolog-
ical obstruction beyond the sac.
The test is performed as follows:
a. Radionuclide technetium-99 is delivered by a micro-
pipette to the lateral conjunctival sac as a 10 µl drop.
The tears are thus labelled with this gamma-emitting
radioactive substance.
b. The tracer is imaged by a gamma camera focused on
the inner canthus and a sequence of images is recorded
over 45–60 minutes (Fig. 2.8D).
Acquired obstruction
Primary punctal stenosis
Primary stenosis occurs in the absence of punctal
eversion.
1. Causes in order of frequency are:
• Associated with chronic blepharitis.
• Idiopathic primary stenosis.
• Herpes simplex and herpes zoster lid infection.
• Following irradiation of malignant lid tumours.
• Cicatrizing conjunctivitis and trachoma.
• Systemic cytotoxic drugs such as 5-fluorouracil
and docetaxel.
• Rare systemic conditions such as porphyria cutanea
tarda and acrodermatitis enteropathica.
2. Treatment
• Dilatation of the punctum can be tried but rarely
gives long-term benefit (Fig. 2.9).
• Punctoplasty is usually required. It involves
removal of the posterior wall of the ampulla by a
two- or three-snip technique (Fig. 2 10).
Secondary punctal stenosis
1. Cause. Secondary stenosis is caused by punctal ever-
sion (see Fig. 2.3A).
2. Treatment
a. Ziegler cautery can be used for pure punctal ever-
sion. Burns are applied to the palpebral conjunc-
tiva, 5 mm below the punctum. Subsequent
shrinkage of the cauterized tissue (cicatrization)
should invert the punctum.
b. Medial conjunctivoplasty can be used in medial
ectropion not associated with lid laxity. A diamond-
shaped piece of tarsoconjunctiva is excised, about
4 mm high and 8 mm wide, parallel with and
infero-lateral to the canaliculus and punctum, fol-
lowed by approximation of the superior and infe-
rior wound margins with sutures (Fig. 2.11).
Incorporation of the lower lid retractors in the
sutures further aids punctal inversion. Once the
punctum is restored to its normal position, it is
dilated or a punctoplasty performed and should
remain open when normal tear flow is established.
c. Lower lid tightening, usually with a lateral canthal
sling, is used to correct lower lid laxity and may
be combined with medial conjunctivoplasty
where there is a significant medial ectropion
component.
Canalicular obstruction
1. Causes include congenital, trauma, herpes simplex
infection, drugs and irradiation. Chronic dacryocysti-
tis can cause a thin membrane to form at the common
canaliculus.
2. Treatment depends on the site and the severity of
obstruction.
a. Partial obstruction of the common or individual
canaliculi, or indeed anywhere in the nasolacrimal
drainage system, may be treated by intubation
 2
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Lacrimal Drainage System 71

A B

C D

Fig. 2.8  Dacryocystography (DCG). (A) Conventional DCG without subtraction shows normal filling on both sides; (B) normal left
filling and obstruction at the junction of the right sac and nasolacrimal duct; (C) digital subtraction DCG shows similar
findings; (D) nuclear lacrimal scintigraphy shows passage of tracer in the right lacrimal system but obstructed drainage in
the left nasolacrimal duct
(Courtesy of A Pearson)

the punctum and the obstruction, is treated by

anastomosis of the patent part of the canaliculus
into the lacrimal sac (canaliculodacryocystorhinos-
tomy – CDCR) and intubation. Where it is not pos-
sible to anastomose the remaining canaliculi to the
sac, treatment involves conjunctivodacryocystorhi-
nostomy and the insertion of a special (Lester
Jones) tube (see below).

Nasolacrimal duct obstruction

A B
Fig. 2.9  Technique of dilating the inferior punctum
using silicone stents through one or both
canaliculi, which are left in situ for 3–6 months
(Fig. 2.12).
b. Total individual canalicular obstruction, with
6–8 mm of patent normal canaliculus between
1. Causes
• Idiopathic stenosis is by far the most common.
• Naso-orbital trauma and previous nasal and sinus
surgery.
• Granulomatous disease such as Wegener granulo-
matosis and sarcoidosis.
• Infiltration by nasopharyngeal tumours.
2. Treatment is with DCR; other techniques include intu-
bation, stent insertion and balloon dilatation.
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A S Y S T E M AT I C A P P ROAC H
B present.
Fig. 2.10  Two-snip punctoplasty; (A) technique; (B) post­
operative appearance
Fig. 2.11  Medial conjunctivoplasty
Dacryolithiasis
Dacryoliths (lacrimal stones) may occur in any part of the
lacrimal system, and are more common in males. Although
the pathogenesis is unclear, it has been proposed that tear
stagnation secondary to inflammatory obstruction may
Fig. 2.12  Silicone tube in situ
precipitate dacryolith formation together with squamous
metaplasia of the lacrimal sac epithelium.
1. Presentation is often in late adulthood and can be
with intermittent epiphora, recurrent attacks of acute
dacryocystitis and lacrimal sac distension.
2. Signs
• The lacrimal sac is distended and relatively firm,
but is not inflamed and tender as in acute
dacryocystitis.
• Mucus reflux on pressure may or may not be
3. Treatment involves DCR.
Congenital obstruction
Nasolacrimal duct obstruction
Duct obstruction is perhaps better termed delayed canali-
zation since it often resolves spontaneously. The lower
end of the nasolacrimal duct (at the valve of Hasner) is
the last portion of the lacrimal drainage system to canal-
ize, complete patency usually occurring soon after birth.
Epiphora affects approximately 20% of neonates, but
spontaneous resolution occurs in 96% of cases within the
first 12 months.
1. Signs
• Epiphora and matting of lashes (Fig. 2.13) may be
constant or intermittent, occurring particularly
when the child has a cold or upper respiratory tract
infection.
• Gentle pressure over the lacrimal sac causes reflux
of purulent material from the puncta.
• Acute dacryocystitis is uncommon (Fig. 2.14).
2. Differential diagnosis includes other congenital
causes of a watering eye such as punctal atresia and
fistulae between the sac and skin (Fig. 2.15). It is also
important to exclude congenital glaucoma in an infant
with a watering eye.
3. Treatment
a. Massage of the lacrimal sac increases the hydro-
static pressure and may rupture the membranous
obstruction. To perform this manoeuvre, the index
finger is placed over the common canaliculus to

Lacrimal Drainage System
Fig. 2.13  Epiphora and matting of lashes
Fig. 2.14  Acute dacryocystitis
block reflux through the puncta and then massaged
firmly downwards. Ten strokes are applied four
times a day. Massage should be accompanied by lid
hygiene; topical antibiotics should be reserved for
superadded bacterial conjunctivitis.
b. Probing of the lacrimal system (Fig. 2.16) should
be delayed until the age of 12–18 months because
spontaneous canalization is likely. Probing per-
formed within the first 1–2 years of life has a very
high success rate, but thereafter the efficacy
decreases. The procedure should be carried out
under a general anaesthetic. The rationale is to
manually overcome the obstructive membrane at
the Hasner valve. After probing, the lacrimal
system is irrigated with saline labelled with fluo-
rescein. If fluorescein can be recovered by aspira-
tion from the pharynx, successful probing is
confirmed. Postoperative steroid-antibiotic drops
are used q.i.d. for up to 3 weeks. If, after 6 weeks,
there is no improvement, repeat probing can be
2
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73
Fig. 2.15  Fluorescein-stained tears in a congenital fistula
between the skin and lacrimal sac
(Courtesy of N Rogers)
Fig. 2.16  Probing of the nasolacrimal duct
(Courtesy of K Nischal)
arranged. Nasal endoscopic monitoring of probing
is recommended, especially for repeat procedures,
to detect anatomical abnormalities and ensure
correct probe alignment.
4. Results are usually excellent and 90% of children are
cured by the first probing and more than half of the
remainder by the second. Failure is usually the result
of abnormal anatomy, which can usually be recog-
nized by difficulty in passing the probe and subse-
quent non-patency of the drainage system on irrigation.
If symptoms persist despite one to two technically
satisfactory probings, temporary intubation with
fine silastic tubes with or without balloon dilatation of
the nasolacrimal duct may affect a cure. Patients
who fail to respond to such measures can be treated
later with DCR, provided the obstruction is distal to
the lacrimal sac.
Congenital dacryocele
A congenital dacryocele (amniontocele) is a collection of
amniotic fluid or mucus in the lacrimal sac caused by an
imperforate Hasner valve.
 Clinical Ophthalmology
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A S Y S T E M AT I C A P P ROAC H
1. Presentation is perinatal.
2. Signs. A bluish cystic swelling at or below
the medial canthus, accompanied by epiphora
(Fig. 2.17). It should not be mistaken for an enceph-
alocele which is characterized by a pulsatile swell-
ing above the medial canthal tendon.
3. Treatment is initially conservative but, if this fails
probing should not be delayed.
Lacrimal surgery
Conventional dacryocystorhinostomy
DCR is indicated for obstruction beyond the medial
opening of the common canaliculus. In principle the
Fig. 2.17  Congenital dacryocele
(Courtesy of A Pearson)
A B
D E
Fig. 2.18  Dacryocystorhinostomy
operation involves anastomosing the lacrimal sac to
the nasal mucosa of the middle nasal meatus. The proce-
dure is usually performed under hypotensive general
anaesthesia.
1. Technique
a. The blood vessels in the middle nasal mucosa are
constricted with ribbon gauze or cotton buds
lightly wetted with 1 : 1000 adrenaline or cocaine
4–10% solution.
b. A straight vertical incision is made 10 mm medial
to the inner canthus, avoiding the angular vein
(Fig. 2.18A).
c. The anterior lacrimal crest is exposed by blunt dis-
section and the superficial portion of the medial
palpebral ligament divided.
d. The periosteum is divided from the spine on the
anterior lacrimal crest to the fundus of the sac and
reflected forwards. The sac is reflected laterally
from the lacrimal fossa (Fig. 2.18B).
e. The anterior lacrimal crest and the bone from the
lacrimal fossa are removed (Fig. 2.18C).
f. A probe is introduced into the lacrimal sac through
the lower canaliculus and the sac is incised in an
‘H-shaped’ manner to create two flaps.
g. Membranous obstruction at the common canalicu-
lar opening or distal canalicular obstruction can be
opened by excision or trephine of obstructing
tissue (canaliculo-DCR).
h. A vertical incision is made in the nasal mucosa to
create anterior and posterior flaps (Fig. 2.18D).
i. The posterior flaps are sutured (Fig. 2.18E).
j. Silicone intubation may be performed.
k. The anterior flaps are sutured (Fig. 2.18F).
l. The medial canthal tendon is resutured to the peri-
osteum and the skin incision closed with inter-
rupted sutures.
2. Results are excellent with a success rate of over 90%.
3. Causes of failure include inadequate size and position
of the ostium, unrecognized common canalicular
C
F
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Lacrimal Drainage System 75

obstruction, scarring and the ‘sump syndrome’, in
which the surgical opening in the lacrimal bone is
too small and too high. There is thus a dilated lacrimal
sac lateral to and below the level of the inferior
margin of the ostium, in which secretions collect,
unable to gain access to the ostium and thence the
nasal cavity.
4. Complications include cutaneous scarring, injury to
medial canthal structures, haemorrhage, cellulitis, and
cerebrospinal fluid rhinorrhoea if the subarachnoid
space is inadvertently entered.
Endoscopic surgery
Endoscopic DCR is usually performed under general
anaesthesia. Advantages over conventional DCR include
the lack of a skin incision, shorter operating time, minimal
blood loss and less risk of cerebrospinal fluid leakage.
Disadvantages include lower success rates, difficulty in
examining the common canalicular opening and reverse
probing of the canaliculus in cases with proximal canal-
icular obstruction. There may be a need for additional
procedures to allow adequate visualization such as cor-
rection of a deviated nasal septum.
1. Technique. A slender light pipe is passed through the
lacrimal puncta and canaliculi into the lacrimal sac
and viewed from within the nasal cavity with an endo-
scope. The remainder of the procedure is performed
via the nose.
a. The mucosa over the frontal process of the maxilla
is stripped.
b. A part of the nasal process of the maxilla is
removed.
c. The lacrimal bone is broken off piecemeal.
d. The lacrimal sac is opened.
e. Silicone tubes are passed through the upper and
lower puncta, pulled out through the ostium and
tied within the nose.
2. Results. The success rate is up to 90%.
infections such as herpes simplex or trachoma,
trauma or radiation. Occasionally a Lester Jones
tube may be used where the lacrimal system is
intact but non-functioning due to pump failure e.g.
chronic facial nerve palsy.
• Secondary placement, following previous DCR
surgery, may be needed for patent but non-
functioning DCRs and where recurrent canalicular
obstruction cannot be opened.
2. Technique for primary insertion
a. A DCR is performed as far as suturing the poste-
rior flaps.
b. The caruncle is partially excised.
c. A stab incision is made with a Graefe knife from a
point about 2 mm behind the inner canthus (under
the former caruncle) in a medial direction, so that
the tip of the knife emerges just behind the anterior
flap of the lacrimal sac (Fig. 2.19A).
d. The track is enlarged sufficiently with dilators to
allow the introduction of a Pyrex Lester Jones tube
(Fig. 2.19B).
e. The incision is sutured as for a DCR.
If the tube falls out it is often possible to replace it without
further surgery if this is done within 24 hours.
Chronic canaliculitis
Chronic canaliculitis is an uncommon condition, fre-
quently caused by Actinomyces israelii, anaerobic Gram-
positive bacteria (Fig. 2.20A). While a diverticulum or
obstruction of the canaliculus can promote anaerobic bac-
terial growth secondary to stasis, in most cases there is no
identifiable predisposition.

Endolaser DCR
Performed with a Holmium:YAG or KTP laser, this is a
relatively rapid procedure which can be carried out under
local anaesthesia. It is therefore particularly suitable for
elderly patients. The success rate is only about 70% but
because normal anatomy is not disrupted it does not
prejudice subsequent surgical intervention in the cases
that fail.

Balloon dacryocystoplasty
Dacryocystoplasty has been used in children with con-
A
genital nasolacrimal duct obstruction and in adults with
partial nasolacrimal duct obstruction. The success rate in
adults is approximately 50%.

Lester Jones tube

1. Indications B
• Primary tube insertion is indicated when there
is extensive proximal canalicular obstruction,
which may be congenital or follow, for example, Fig. 2.19  Insertion of Lester Jones tube
 Clinical Ophthalmology
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A S Y S T E M AT I C A P P ROAC H

A B

C D

Fig. 2.20  Chronic canaliculitis. (A) Gram stain of Actinomyces israelii; (B) mucopurulent discharge; (C) oedema of the upper
canaliculus; (D) mucopurulent discharge from the upper canaliculus on pressure; (E) sulphur concretions
(Courtesy of J Harry – fig. A; A Pearson – fig. B; S Tuft – fig. E)
 2
CHAPTER
Lacrimal Drainage System 77

Diagnosis
1. Presentation is with unilateral epiphora associated
with chronic mucopurulent conjunctivitis (Fig. 2.20B),
refractory to conventional treatment.
2. Signs
• A ‘pouting’ punctum is a diagnostic clue in mild
cases (see Fig. 2.3E).
• Pericanalicular inflammation characterized by
oedema of the canaliculus (Fig. 2.20C).
• Mucopurulent discharge on pressure over the
canaliculus (Fig. 2.20D).
• Concretions consisting of sulphur granules may be
expressed on canalicular compression with a glass
rod or become evident following canaliculotomy
(Fig. 2.20E).
• In contrast to dacryocystitis, there is no naso­
lacrimal duct obstruction, or lacrimal sac disten- A
sion or inflammation.

Treatment
1. Topical antibiotics such as levofloxacin q.i.d. for 10
days may be tried initially but are rarely curative
alone.
2. Canaliculotomy involving a linear incision into the
conjunctival side of the canaliculus and curetting of
the concretions is the most effective treatment which
should be combined with topical antibiotics. Occa-
sionally it may result in scarring and interference with
canalicular function.

Differential diagnosis
1. The ‘giant fornix syndrome’ may also cause chronic
relapsing purulent conjunctivitis. This is due to
retained debris in the upper fornix that is colonized by B
S. aureus, usually in elderly patients with levator dis­
insertion. Secondary corneal vascularization and lac-
rimal obstruction are common. Treatment involves
thorough cleaning of the fornix, and topical and sys-
temic antibiotics.
2. Other conditions that may cause similar symptoms
include a lacrimal diverticulum and a lacrimal stone.
Herpes simplex infection can cause an acute
canaliculitis.

Dacryocystitis
Infection of the lacrimal sac is usually secondary to
obstruction of the nasolacrimal duct. It may be acute or
chronic and is most commonly staphylococcal or
streptococcal.

Acute dacryocystitis
1. Presentation is with the subacute onset of pain in the
medial canthal area, associated with epiphora.
2. Signs
• Very tender tense red swelling at the medial
C
Fig. 2.21  (A) Acute dacryocystitis; (B) lacrimal abscess and
preseptal cellulitis; (C) lacrimal fistula
(Courtesy of A Pearson)

canthus that may be associated with preseptal cel-

lulitis (Fig. 2.21A).
• Abscess formation (Fig. 2.21B) may occur.
 Clinical Ophthalmology
78
A S Y S T E M AT I C A P P ROAC H

3. Treatment
a. Initial treatment involves the application of local
warm compresses and oral antibiotics such as flu-
cloxacillin or co-amoxiclav; irrigation and probing
should not be performed.
b. Incision and drainage may be considered if pus
points and an abscess is about to drain spontane-
ously. However, this carries a risk of the develop-
ment of a lacrimal fistula, which may serve as a
conduit for tears from the lacrimal sac to the skin
surface (Fig. 2.21C).
c. DCR is usually necessary after the acute infection
has been controlled. Surgery should not be delayed
in the presence of persistent epiphora because of
the risk of recurrent infection.

A
Chronic dacryocystitis
1. Presentation is with epiphora, which may be associ-
ated with a chronic or recurrent unilateral conjuncti-
vitis. It is wise to postpone intraocular surgery till
lacrimal infection has been treated, owing to the grave
risk of endophthalmitis.
2. Signs
• A painless swelling at the inner canthus caused
by a mucocele (Fig. 2.22A).
• Obvious swelling may be absent, although pres-
sure over the sac commonly still results in reflux
of mucopurulent material through the canaliculi
(Fig. 2.22B).
3. Treatment involves DCR.

Fig. 2.22  (A) Mucocele; (B) expression of mucopurulent

material
(Courtesy of R Bates – fig. A)